The American Board of Internal Medicine (ABIM) made headlines in late 2024 when it announced the elimination of its unpopular two-year Maintenance of Certification (MOC) point requirement. On paper, this looked like progress, a gesture toward simplification after years of criticism from physicians who felt trapped in an expensive, time-consuming cycle that added little value to their actual practice. But beneath the surface, the reform raises a harder question: Has anything truly changed, or did the ABIM simply remove one layer from a system that’s been broken for decades?

The modern certification maze

Let’s imagine a few different physicians making their way through today’s certification maze, situations that mirror what many of us deal with every year. Dr. Patel is a mid-career gastroenterologist who finished training in the early 2000s. Every five years she’s back in the loop: tracking points, paying fees, and logging onto ABIM’s Longitudinal Knowledge Assessment (LKA). It’s a steady hum of administrative maintenance, answering questions that may or may not reflect the day-to-day complexity of her practice.

Down the hall, Dr. Reynolds, who certified before 1990, never has to do any of it. He’s “boarded for life.” Same credential, same privileges, same hospital staff title. One physician spends hundreds of hours proving ongoing competence; the other never has to lift a finger. If lifelong learning truly matters, and it does, this double standard erodes the logic of the system. Either the knowledge decay we all worry about is real, or it isn’t. Both can’t be true.

The CME tangle

Then there’s the state-licensing layer, a separate, equally tangled web that almost no one outside medicine understands. Each state medical board has its own continuing education rules, ranging from 20 to 100 hours every renewal cycle. The content varies wildly: opioid prescribing in one state, human trafficking awareness in another, implicit bias or domestic violence training somewhere else. Most are worthy subjects, and few dispute that. But for specialists, much of it feels distant from the realities of subspecialty care.

Consider Dr. Harris, a composite of many mid-career physicians doing locums work across multiple states. She keeps active licenses in Illinois, Florida, and Arizona. Each state has its own clock ticking on CME requirements, with different reporting portals, formats, and deadlines. She estimates she spends nearly 80 hours a year fulfilling mandatory CME, and not one of those hours automatically counts toward her ABIM MOC credit unless she pays a conversion fee or attends a double-certified course. It’s not the learning that’s the problem. It’s the redundancy. The system confuses activity with competence.

When every gatekeeper wants proof

For physicians who work locums or telemedicine, or who just keep multi-state licenses to cover seasonal or consulting work, the cumulative burden becomes staggering. Different states require different CME topics. Hospitals tack on their own credentialing modules. Insurers add yearly compliance training. Then ABIM emails its LKA reminders. Every organization wants a box checked, a certificate uploaded, a fee paid. None of them talk to each other.

A physician covering 5 states may need to track 5 CME renewal dates, 5 sets of documentation, and a separate log-in for every system. The irony is hard to miss: We practice medicine in an era of electronic health records, telehealth, and AI-supported diagnostics, yet our professional maintenance still feels like navigating a bureaucratic spreadsheet from 1995.

ABIM’s 2024 “simplification”

When ABIM removed the two-year MOC point checkpoint, it framed the decision as cutting unnecessary red tape. “The requirement didn’t provide added value,” the board said, an admirable admission but also a revealing one. Because that’s the entire issue. The requirement never had evidence behind it in the first place. And there’s still no published data showing that the current model, 100 points every five years and ongoing participation in LKA, actually improves patient care.

The LKA was meant to replace the high-stakes, once-a-decade exam with something less stressful and more continuous. On paper, it’s friendlier: short online question sets that can be answered from home. But for many, it feels like perpetual testing in disguise: One more inbox reminder, one more password, one more thing to do before dinner. No randomized or longitudinal studies have shown that physicians enrolled in LKA deliver better outcomes or safer care than those certified through older pathways. The assumption that constant quizzing equals better practice remains untested.

A system built on fragmentation

Today, every practicing physician is accountable to at least three overlapping bureaucracies:

• State medical boards: Enforcing CME topics that often have little overlap with specialty training.
• Specialty boards: Each with its own maintenance calendar, point system, and exam format.
• Hospitals and payers: Adding their own credentialing, ethics modules, and compliance training.

None of these entities share data or accept each other’s documentation. None have proven that their requirements improve patient outcomes. All of them collect fees. This fragmented oversight might make sense if it protected patients or improved care. But there’s no convincing evidence that it does. Instead, it has become a sprawling self-perpetuating compliance industry, one that values documentation over development.

Grandfathered for life

The generational inequity only makes matters worse. Thousands of physicians certified before 1990 remain permanently credentialed, exempt from MOC entirely. Many are superb clinicians. Some, inevitably, are out of touch with new therapies, devices, and safety guidelines, but the system doesn’t differentiate. Meanwhile, younger physicians spend thousands of dollars and countless hours maintaining the same certificate, knowing full well that others with identical credentials face none of the same obligations. If recertification is truly essential for patient safety, why was the first generation excused from it? And if it isn’t, why are the rest of us still doing it?

What the evidence really shows

Research linking board certification to patient outcomes has always been modest and indirect. A handful of older studies found that certified physicians were slightly more likely to follow preventive care guidelines or order recommended tests. But these studies pre-date the current MOC models and have never isolated the effect of maintenance activities themselves.

There’s no proof that answering LKA questions translates into lower readmission rates, fewer endoscopic complications, or improved chronic disease control. In other words, the data behind MOC as an instrument of quality are as thin now as they were when the process began. Meanwhile, burnout and attrition continue to rise. Mid-career physicians, the very group ABIM claims to support with its “flexible” new model, report spending more hours on maintenance than on actual professional development that benefits their patients.

A vision for real reform

If we want maintenance of certification to mean something, it has to align with how medicine actually evolves. That means:

• Reciprocity: Specialty-relevant CME should satisfy both state and board requirements. A single, high-quality educational activity ought to count everywhere.
• Transparency: Boards should publish clear, peer-reviewed data showing that their programs improve care or patient safety.
• Equity: Grandfather clauses should sunset. If maintenance is vital, it’s vital for everyone.
• Portability: Physicians should have one digital credentialing portfolio that tracks CME, board activities, and state compliance automatically, a single verified source accessible to hospitals and payers.

That’s not science fiction; it’s standard in many industries that regulate safety and competence. Aviation and engineering manage it. Medicine should too.

What this means

The ABIM’s 2024 reforms were a step, not a solution. Dropping an unnecessary rule is easy; proving that what remains has value is much harder. Physicians aren’t asking for a free pass. We’re asking for coherence, for systems grounded in data rather than ritual. Most of us already engage in lifelong learning because the practice itself demands it. What we resent is the ever-expanding bureaucracy that confuses compliance with competence.

Until maintenance of certification and CME requirements are harmonized, evidence-based, and equitable, every “reform” will feel cosmetic. And for the physician juggling three state licenses, a full clinic, and another LKA notification blinking in her inbox, that cosmetic change won’t make her a better doctor, just a busier one.

Courts, credentialing, and choice: the legal fights around MOC

The tension between physicians and the American Board of Internal Medicine (ABIM) has simmered for more than a decade. What began as a professional debate over maintenance of certification (MOC) has evolved into a broader question of fairness, autonomy, and accountability. Now, the courts are involved, and the legal battles are revealing as much about the profession’s frustration as they are about the structure of American medicine itself.

A landscape of lawsuits

Since 2018, multiple physician-led lawsuits have challenged the legality of the ABIM’s business model. The most visible, Association of American Physicians & Surgeons (AAPS) v. ABIM, claims that the organization uses its monopoly on certification to force physicians into costly, time-consuming recertification cycles under threat of professional exclusion.

A federal district court initially dismissed much of the case in 2022, but in 2024, the Fifth Circuit Court of Appeals revived key portions, allowing it to proceed. The legal argument is complex, but the essence is simple: Physicians allege that ABIM’s MOC requirements, bundled with its initial certification monopoly, create an anticompetitive system that unfairly ties one product (initial certification) to another (ongoing maintenance). It’s a case that gets to the heart of physician autonomy, and one that could reshape the entire certification landscape if courts ultimately find that MOC participation is being coerced under antitrust law.

More than just a legal fight

Let’s imagine a few different practicing physicians navigating the ripple effects of this controversy. Dr. Nguyen, a hospitalist, needs her certification to stay on staff at her hospital. The credential is required by both the bylaws and her malpractice insurer. When she expresses skepticism about the value of MOC, her administrator reminds her that “certification is mandatory for hospital credentialing.” She has no real choice.

Across town, Dr. Lawson, a cardiologist in private practice, opts to drop out of MOC altogether after failing to see any clinical benefit. He still holds his original certification, but without ongoing maintenance, ABIM marks him as “not participating.” His insurer flags the change, his hospital re-evaluates his privileges, and his profile on the ABIM website now implies his certification has “lapsed.” Neither of these physicians is breaking the law, yet both are effectively trapped. Their livelihood depends on maintaining a credential that is, by most definitions, voluntary.

What the lawsuits argue

The plaintiffs in these cases argue that ABIM’s control over certification has become so entrenched that participation in its MOC program is no longer optional in any meaningful sense. They point out that hospitals, payers, and insurers often treat ABIM certification as a de facto requirement for employment or credentialing.

That’s where the legal argument of tying comes in, a concept from antitrust law that prohibits companies from forcing customers to buy one product as a condition of buying another. In this analogy, the “product” is certification: Doctors must first purchase initial certification and then continually purchase MOC to maintain access to it. ABIM counters that participation in MOC is voluntary, that its processes serve the public interest by ensuring ongoing competence, and that hospitals and insurers, not ABIM, make credentialing decisions. Yet from the perspective of working physicians, the difference between voluntary and required has become semantic. In modern practice, “voluntary” certification is about as optional as paying your malpractice premium.

Credentialing as a choke point

At the heart of this conflict lies the modern credentialing ecosystem, a web of overlapping requirements that give MOC its real-world power. Hospitals, insurers, and health systems increasingly use board certification status as a proxy for quality. The logic is straightforward: A certified physician has demonstrated competence through training and examination, so maintaining certification must signify continued excellence.

But this assumption has never been validated. No large-scale studies have shown that hospitals requiring MOC achieve better patient outcomes than those that do not. Instead, what has emerged is a circular system: Boards require maintenance, hospitals require board recognition, insurers require credentialing, and physicians must comply or risk professional exile. The result is a quiet but powerful form of coercion, one that no single organization takes responsibility for.

The cost of compliance

Dr. Adams, a fictional but realistic mid-career pulmonologist, once calculated his own “MOC tax.” Between exam fees, travel, CME purchases, and time away from his practice, he spent roughly $5,000 every five years just to remain in good standing. Multiply that across the more than 200,000 ABIM diplomates, and the financial magnitude becomes clear. The board’s tax filings reflect tens of millions in annual revenue tied directly to maintenance of certification. Critics argue that this structure incentivizes the continuation of burdensome requirements regardless of their proven benefit. In their view, MOC has become less about professional development and more about sustaining an administrative enterprise.

Fragmented oversight, fragmented accountability

ABIM operates as one of 24 member boards under the American Board of Medical Specialties (ABMS). Each member board sets its own standards, timelines, and fees. While ABMS provides overarching principles, there is no unified accountability mechanism to evaluate whether these maintenance systems actually improve care.

Meanwhile, alternative certifying bodies such as the National Board of Physicians and Surgeons (NBPAS) have emerged, offering CME-based recertification without exams or point systems. Some hospitals and insurers accept NBPAS credentials; others don’t. That inconsistency has created what might best be called “credentialing by ZIP code.” A physician might be recognized in one state but disqualified in another, not because of competence, but because of institutional politics.

Legal reform vs. professional reform

Even if the lawsuits against ABIM eventually succeed, legal remedies alone may not fix the underlying problem. Courts can address anticompetitive behavior, but they cannot legislate professional coherence or rebuild trust between physicians and their certifying bodies. True reform will require medicine itself to decide what continued certification should mean and how to align it with actual, measurable outcomes. That means defining what we are trying to prove through these processes. Is it ongoing competence? Lifelong learning? Patient safety? If the answer is “all of the above,” then the system must demonstrate evidence for each, not simply assume it.

An uneasy status quo

For now, the legal battles continue. ABIM’s reforms, such as the 2024 elimination of the two-year point check-in, were designed to reduce friction, not to address the monopoly question. The board continues to defend MOC as necessary for public accountability and professional integrity. But among working physicians, skepticism runs deep. Many see the board’s moves as reactive, incremental changes made only under pressure from lawsuits and growing competition.

Dr. Patel summed it up best during a recent grand rounds discussion: “It’s not that we don’t believe in lifelong learning. We just don’t believe in paying for it twice.”

A path forward

Rebuilding trust will require more than eliminating redundant rules. It will demand transparency about where the money goes, evidence that the time and expense improve outcomes, and a reimagining of certification as a tool for learning, not punishment. A good start would be a truly portable credentialing system that integrates CME, specialty maintenance, and state licensure. Physicians should be able to demonstrate ongoing competence through meaningful metrics: peer-reviewed case evaluations, clinical performance benchmarks, or documented quality improvement projects, all verified through a shared national database, not a dozen separate portals.

As for the courts, they may soon decide whether ABIM’s current structure crosses the legal line between quality assurance and market control. But even if the rulings go in ABIM’s favor, the profession’s confidence will not return until the system itself does more than check boxes and collect fees. Until then, physicians will keep doing what they’ve always done: learning, improving, and caring for patients, often in spite of the very organizations that claim to represent that effort.

Brian Hudes is a gastroenterologist.